BACKGROUND: We sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses. METHODS: Patients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair. RESULTS: Four hundred and eleven grafts were followed up for a median of 19 months (range: 2-61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P=0.08) or amputation rates (P=0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51-4.53), (P=0.006)], diabetes [OR: 2.55 (95% CI: 1.49-4.35), (P=0.006)], renal failure [OR: 1.89 (95% CI: 1.19-3.38), (P=0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63-4.69), (P<0.001)] were risk factors for graft occlusion. CONCLUSIONS: Balloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.